Suture retainer with multiple circumferentially spaced attachment points and suture retention method

ABSTRACT

The suture retainer according to one aspect of the invention has a retainer body and a plurality of suture attachment mechanisms spaced circumferentially about the retainer body, each of the suture attachment mechanisms (such as a pair of teeth) being adapted to hold a suture strand at a discrete attachment point. Another aspect of the invention provides a method of securing a suture in a suture retainer, including the following steps: providing a suture retainer having a retainer body and a plurality of suture attachment mechanisms spaced circumferentially about the retainer body; and attaching a suture strand to the retainer body at each of the suture attachment mechanisms. Yet another aspect of the invention provides a suturing method including the steps of: attaching a first end of a suture strand to a suture retainer; contacting a tissue contact portion of the suture strand with tissue to be sutured, the tissue contact portion being disposed between the first end of the suture strand and a second end of the suture strand; and attaching the second end of the suture strand to the suture retainer at a plurality of suture attachment points spaced circumferentially about the suture retainer.

BACKGROUND OF THE INVENTION

The invention relates generally to suture retainers and methods of usingsuture retainers. In particular, the invention relates to sutureretainers that hold a suture strand at a plurality of circumferentiallyspaced points about the suture retainer.

Sutures are used for a variety of surgical purposes, such asapproximation of tissue and ligation of tissue. Most generally, whenplacing sutures, the strand of suture material to be used has a needleaffixed to one end. The needle is passed through the tissue to beapproximated or ligated, forming a stitch. The stitch is then tensionedappropriately, and the two ends of the suture, the needle end and thenon-needle end, are knotted to retain the desired tension in the stitch.Sometimes the ends are knotted together; in other instances they may bestoppered separately, often with the aid of a clip or other device toform resistance to passage through tissue. While forming knots in sutureduring open surgery is a simple matter, forming knots in suture duringendoscopic surgery can be very difficult.

Suture retainers may be used in place of suture knots to prevent passageof a suture end into and through tissue and to maintain the tensionapplied to the suture material during the suturing procedure. Sutureclips and other suture retainers are described in the followingpublications: U.S. Pat. No. 5,234,449; U.S. Pat. No. 5,383,905; U.S.Pat. No. 5,391,173; U.S. Pat. No. 5,643,295; U.S. Pat. No. 5,645,553;U.S. Pat. No. 5,735,877; U.S. Pat. No. 5,845,645; U.S. Pat. No.5,895,393; U.S. Pat. No. 6,015,428; U.S. Pat. No. 6,066,160; U.S. Pat.No. 6,231,592; and U.S. Pat. No. 6,432,123.

SUMMARY OF THE INVENTION

The present invention provides a suture retainer with multiplecircumferentially spaced attachment points. The invention also providesa suture retainer with a suture guide mechanism adapted to maintain anangle between a suture strand and a suture attachment mechanism. Whilethe suture retainer of this invention can be used in conventional opensurgeries or external surgeries, the invention is particularly usefulfor endoscopic suturing.

The suture retainer according to one aspect of the invention has aretainer body and a plurality of suture attachment mechanisms spacedcircumferentially about the retainer body, each of the suture attachmentmechanisms (such as a pair of teeth) being adapted to hold a suturestrand at a discrete attachment point. In some embodiments, each sutureattachment mechanism is adapted to releasably hold the suture strand.

In some embodiments of the invention, the suture retainer also has asuture guide mechanism, such as a projection from the retainer body,adapted to maintain an angle between the suture strand and one of thesuture attachment mechanisms. The suture guide mechanism may be adaptedto be a first contact point of the suture strand with the sutureretainer.

In some embodiments, the suture attachment mechanisms are needle-endsuture attachment mechanisms, with the suture retainer also including anon-needle-end suture attachment mechanism adapted to hold anon-needle-end of the suture strand. The non-needle-end sutureattachment mechanism may be disposed radially inward from each of theneedle-end suture attachment mechanisms. Also, in some embodiments, theretainer body has a first member and a second member, with at least aportion of the second member being adapted to be inserted into the firstmember to form the non-needle-end suture attachment mechanism, such as aslot in the second member which interacts with the first member to holdthe non-needle-end of the suture strand. The suture retainer may alsohave an alignment mechanism adapted to orient the second member withrespect to the first member. In some embodiments, the suture retaineralso has a movable connection between the first member and the secondmember, and in some embodiments the suture retainer has a snapconnection between the first member and the second member. In someembodiments, a suture guide mechanism may project from the first and/orsecond member.

Another aspect of the invention provides a method of securing a suturein a suture retainer, including the following steps: providing a sutureretainer having a retainer body and a plurality of suture attachmentmechanisms spaced circumferentially about the retainer body; andattaching a suture strand to the retainer body at each of the sutureattachment mechanisms. In some embodiments, each suture attachmentmechanism is at least a pair of teeth, with the method further includingthe step of inserting the suture strand between each of the pairs ofteeth. The method may also include the step of releasing the suturestrand from the suture attachment mechanisms after the attaching stepand possibly the step of reattaching the suture strand to the sutureattachment mechanisms after the releasing step.

In some embodiments the method also includes the step of contacting thesuture strand with a suture guide to maintain an angle between thesuture strand and one of the suture attachment mechanisms. Thecontacting step may include the step of contacting with the suture guidea portion of the suture strand between a point where the suture strandleaves a tissue surface and a point where the suture strand contacts asuture attachment mechanism.

In some embodiments, the attaching step includes the step of attaching aneedle-end of the suture strand to needle-end suture attachmentmechanisms, with the method further including the step of attaching anon-needle-end of the suture strand to the suture retainer. The retainerbody may include a first member and a second member, and the step ofattaching the non-needle-end of the suture strand may include the stepof inserting at least a portion of the second member into the firstmember to hold the non-needle-end of the suture strand. In embodimentsin which the retainer body has a movable connection between the firstmember and the second member, the inserting step may include the step ofmoving the second member about the movable connection with respect tothe first member and possibly the step of snapping the first and secondmembers together.

Yet another aspect of the invention provides a suturing method includingthe steps of: attaching a first end of a suture strand to a sutureretainer; contacting a tissue contact portion of the suture strand withtissue to be sutured, the tissue contact portion being disposed betweenthe first end of the suture strand and a second end of the suturestrand; and attaching the second end of the suture strand to the sutureretainer at a plurality of suture attachment points spacedcircumferentially about the suture retainer. In some embodiments, thestep of attaching the second end of the suture strand includes the stepof placing the second end of the suture strand between a plurality ofpairs of teeth, each pair of teeth being disposed at one of the sutureattachment points. The method may also include the step of detaching thesuture strand from the suture attachment mechanisms after the attachingstep and possibly the step of reattaching the suture strand to thesuture attachment mechanisms after the detaching step.

In some embodiments, the step of attaching the first end of the suturestrand includes the step of inserting at least a portion of a firstsuture retainer body member into a second suture retainer body member.The attaching step may also include the step of placing the first end ofthe suture strand into a slot formed in the first suture retainer bodymember. The inserting step may include the step of aligning the firstsuture retainer body member with the second suture retainer body member,such as by rotating the second body member to align a second sutureretainer body member alignment element with a first suture retainer bodymember alignment element.

Some embodiments of this aspect of the invention include the step ofcontacting the second end of the suture strand with a suture guide tomaintain an angle between the suture strand and one of suture attachmentmechanisms, such as by making a first contact of the second end of thesuture strand with the suture retainer.

INCORPORATION BY REFERENCE

All publications and patent applications mentioned in this specificationare herein incorporated by reference to the same extent as if eachindividual publication or patent application was specifically andindividually indicated to be incorporated by reference.

BRIEF DESCRIPTION OF THE DRAWINGS

The novel features of the invention are set forth with particularity inthe appended claims. A better understanding of the features andadvantages of the present invention will be obtained by reference to thefollowing detailed description that sets forth illustrative embodiments,in which the principles of the invention are utilized, and theaccompanying drawings of which:

FIG. 1 is a side elevational view of a suture retainer according to oneembodiment of this invention.

FIG. 2 is a side elevational view of the suture retainer of FIG. 1,partially assembled.

FIG. 3 is a side elevational view of a plug portion of the sutureretainer of FIG. 1.

FIG. 4 is a top elevational view of the plug portion of the sutureretainer shown in FIG. 3.

FIG. 5 is a medial cross-sectional view of the wheel portion of oneembodiment of the suture retainer of this invention with a suture strandlaid into the attachment mechanisms.

FIG. 6 is a side elevational view of the wheel portion of the sutureretainer shown in FIG. 1.

FIG. 7 is a perspective view of the suture retainer shown in FIG. 1.

FIG. 8 shows a suture retainer according to one embodiment of thisinvention in use to retain a suture strand.

FIG. 9 is a top elevational view of a suture attachment feature that maybe used with embodiments of this invention.

FIG. 10 is a top elevational view of the wheel portion of yet anotherembodiment of the suture retainer of this invention.

FIG. 11 is a cross-sectional view taken along the line A-A of FIG. 10.

FIG. 12 is a side elevational view of the plug portion of the embodimentof FIG. 10.

FIG. 13 is a schematic view of an assembled suture retainer according tothe embodiment of FIGS. 10-12 showing a suture in place.

FIG. 14 is a top elevational view of the wheel portion of anotherembodiment of the suture retainer of this invention.

FIG. 15 is a cross-sectional view taken along the line A-A of FIG. 14.

FIG. 16 is a top elevational view of the plug portion of the embodimentof FIG. 14.

FIG. 17 is a cross-sectional view of a suture and a partially assembledsuture retainer according to the embodiment of FIGS. 14-16, prior touse.

DETAILED DESCRIPTION OF THE INVENTION

FIGS. 1-7 show embodiments of a suture retainer 10 with two principalparts: a wheel portion 12 and a plug portion 14. Wheel portion 12 hassets of teeth 16 arranged around its circumference. As shown best inFIG. 7, tooth sets 16 each have a pair of inclined facing edges 18 and20 that diverge from the center of wheel portion 12 toward the outercircumference of wheel portion 12. The spacing and angle of inclinedsurfaces 18 and 20 are chosen to engage the diameter of the suturestrand with which the retainer is intended to be used. In oneembodiment, for example, the angle between the inclined surfaces of eachtooth set is about 10° or less.

In the embodiments shown in FIGS. 1-7, wheel portion 12 has three setsof teeth arranged about the circumference of wheel portion 12 in amanner to produce pull angles of between about 50° and 70° for eachtooth set. Pull angle is defined as the angle formed on the “pull” sideof the tooth set between a suture held by the tooth set and a linenormal to a plane formed by the juxtaposed edges of the teeth. The toothsets extend radially from the center of wheel portion 12 or may extendon an angle from a radius in order to provide the desired pull angle. Inother embodiments, the suture retainer may have one, two or more thanthree sets of suture attachment mechanisms, such as the teeth shown inthe embodiments of FIGS. 1-7.

A pair of plates or flanges 22 and 24 surround and support the toothsets. Plates 22 and 24 also aid the surgeon in passing the needle end ofthe suture around wheel portion 12 to engage successive tooth sets.Wheel portion 12 has a central opening 26 and an alignment hole 28.Opening 26 and hole 28 mate with corresponding portions of plug portion14 when the suture retainer is assembled.

Plug portion has lock arms 30 and 32 extending from a plate 34. Lockarms 30 and 32 have cam surfaces 36 and 38, respectively that areadapted to bend arms 30 and 32 inward when surfaces 36 and 38 engage theedges of opening 26 in wheel portion 12. A slot 40 is formed betweenarms 30 and 32.

Also extending from plate 34 is a suture guide mechanism (such as hook42 in FIG. 1 or tab 50 in FIG. 7) and an alignment member 44. Alignmentmember 44 extends into alignment hole 28 when plug portion 14 isconnected to wheel portion 12. This arrangement sets the position of thesuture guide mechanism (e.g., hook 42) with respect to one of the toothsets 16 so that hook may serve as a retainer or guide for a suturestrand as it enters a first tooth set 16, as described below. Othermeans of aligning the plug and wheel portions of the suture retainer maybe used, of course, without departing from the invention.

To use the suture retainer, the non-needle-end of a suture is insertedinto the slot 40, preferably when the suture retainer is in thepartially assembled configuration shown in FIG. 3. Plug portion 14 isthen advanced completely into wheel portion 12, with alignment member 44aligned with alignment hole 28. As lock arms 30 and 32 move into opening26, cam surfaces 36 and 38 engage the edges of opening 26 to move arms30 and 32 inward. After cam surfaces 36 and 38 have completely passedthrough opening 26, arms 30 and 32 move outwardly so that lock surfaces46 and 48 formed on arms 30 and 32, respectively, engage the far side ofplate 24 in a snap connection, as shown in FIGS. 1 and 7, and the suturestrand is gripped firmly, preferably in a controlled clearance spacebetween the shaft of the plug and the bore of the wheel.

When thus assembled, the non-needle-end of the suture strand is heldfirmly by suture retainer 10. The surgeon can then pass the needle andneedle-end of the suture strand through and/or around the tissue 2 to besutured or ligated, pulling suture retainer 10 against the surface ofthe tissue, as shown in FIG. 8. When the suture stitch is complete, thesurgeon passes the needle-end 6 of the suture strand 4 around and inengagement with the suture guide mechanism 42, tensions the stitch, thenguides the needle-end of the suture strand in succession into the threesets of teeth 16, maintaining the tension in the suture strand as thesurgeon progresses. If the stitch tension and suture retainer grip aresatisfactory, the surgeon then may sever the unused ends of the suturestrand. If, however, the stitch needs to be retensioned to eitherincrease or decrease tissue approximation or the retainer grip needs tobe adjusted, the surgeon may pull the suture strand away from the toothsets, then retension the stitch and reengage the suture strand with thesuture retainer. While the illustrations show a clockwise wrapping ofthe suture, other embodiments of the invention may employcounterclockwise wrapping of the suture around the retainer.

The shape and position of hook 42 help retain the suture strand'sorientation and pull angle with respect to the first set of teeth 16 itencounters. In addition, the curved end of hook 42 helps retain thesuture strand in place after the suturing procedure has been completed.Other shapes and manners of suture strand guides may be used in place ofhook 42, such as tabs, posts, rings, etc. In addition, the suture strandguide of this invention may be used with suture retainers having one,two or more than three suture attachment mechanisms.

FIG. 9 shows an optional feature for holding the far end of theneedle-end of the suture strand after engagement with the retainer'ssets of teeth. A slot 54 is formed in plate 24 of suture retainer 10.The end of the suture strand may be placed within slot 54 to provideadditional retention of the suture and to maintain the retention of thesuture provided by the last set of teeth before severing and removingthe needle end of the suture. The slot may be tapered or parallel, asshown, and may be used with any of the embodiments of this invention.This feature may also be used to retain one end of a suture strandwithout regard to whether, or the manner in which, the other end of thesuture strand is retained.

Another embodiment of the invention is shown in FIGS. 10-13. Sutureretainer 60 has a wheel portion 62 and a plug portion 64. Like theprevious embodiments, wheel portion 62 has sets of teeth 66 arrangedabout a circumference of wheel portion 62. A pair of plates or flanges68 and 70 surround and support the tooth sets. Wheel portion 62 also hasa central opening 72 with a movable member 74 formed inside the opening.A suture guide mechanism 76 extends from wheel portion 62.

Plug portion 64 has a slot 78 and a groove 80. A tab 82 extends from thetop surface of plug portion 64. Prior to insertion (or after partialinsertion) of plug 64 into wheel 62 in the direction shown by the arrowin FIG. 11, the non-needle-end of a suture strand 86 may be insertedinto slot 78 and, if desired, wrapped around groove 80 and back throughslot 78. Plug 64 is then inserted fully into opening 72 of wheel 62 fromthe bottom, as shown in FIG. 11. As it is inserted, the plug's tab 82pushes the top of the wheel's movable member 74 radially away from thecenter of opening 72. When the plug's tab 82 reaches a space 84 abovemovable member 74, movable member 74 moves back toward the center ofopening 72, snapping plug 64 in place within wheel 62. In this position,the non-needle-end of suture strand 86 is held firmly by suture retainer60. The suture thread may be tensioned downward, as shown in FIG. 13.

After assembly of the suture retainer, the surgeon may then use theneedle-end of the suture to perform the suturing or ligation procedure.As in the other embodiments, when the suture stitch is complete, thesurgeon passes the needle-end of the suture strand around the sutureguide 76, then inserts the suture strand in succession into the sets ofteeth 66. Thereafter, the surgeon may place the needle-end of the suturestrand into a slot 88 formed in plate or flange 68.

In the embodiment shown in FIGS. 10-13, the top and bottom edges of plug64 lie flush with the top and bottom edges of wheel 62. This arrangementis an optional feature of the invention. Also, it should be understoodthat other suture attachment mechanisms and other numbers of sutureattachment mechanisms may be used in the suture retainer of thisinvention.

FIGS. 14-17 show yet another embodiment of this invention. Sutureretainer 100 has a wheel portion 102 and a plug portion 104. Like theprevious embodiments, wheel portion 102 has sets of teeth 106 arrangedabout a circumference of wheel portion 102. A pair of plates or flanges108 and 110 surround and support the tooth sets. Wheel portion 102 alsohas a central opening 112 with a movable arm 114 formed inside theopening. A suture guide mechanism 116 extends from wheel portion 112.

Plug portion 104 has a pair of pins 107 extending from an upper surface.When the suture retainer is assembled prior to use, pins 107 are snappedinto openings formed by pairs of arms 118 extending upward from theupper surface of flange 108 of wheel 102 to form a hinge to allowrotational movement between plug 104 and wheel 102. Other forms ofmovable connection between the plug and wheel are also covered by thisinvention.

FIG. 17 shows the arrangement of plug 104 and wheel 102 prior to use ofthe suture retainer. A loop 120 formed in the non-needle-end of a suturestrand is passed up through opening 112. The suture strand may then bewrapped one or more times around plug 104 with the suture strand lyingin grooves 122 (and groove 123, for multiple suture wraps) formed inplug 104. Plug 104 is then rotated downward about the hinge formed bypins. 107 and arms 118. As the bottom of plug 104 enters opening 112, anangled surface 124 of plug 104 engages an angled surface formed on thetop of a tab 126 of movable arm 114, pushing the top of arm 114 radiallyoutward. When plug 104 has been completely inserted into wheel 102, tab126 moves radially inward into a slot 128 formed in plug 104 to latchplug 104 in place within wheel 102. The surgeon may then use theneedle-end of the suture to perform the suturing or ligation procedure.As in the other embodiments, when the suture stitch is complete, thesurgeon passes the needle-end of the suture strand around the sutureguide 116, then inserts the suture strand in succession into the sets ofteeth 106 to hold the suture in place.

The use of circumferentially spaced tooth sets provides multiple sutureattachment mechanisms each at desired pull angles. This arrangementreduces the likelihood of slippage of the suture strand in the event oneof the attachment points fails or provides less than 100% of therequired tensioning force. Other numbers of tooth sets set at other pullangles may also be used. In addition, other attachment mechanisms may beused in place of the tooth sets described above, such as high frictionsurfaces, hooks, posts, rings, etc.

The components of the device described above can be made of medicallysuitable metal or plastics, including bio-absorbable polymers. Examplematerials include stainless steel, polycarbonate and polyglycolide.

While preferred embodiments of the present invention have been shown anddescribed herein, it will be obvious to those skilled in the art thatsuch embodiments are provided by way of example only. Numerousvariations, changes, and substitutions will now occur to those skilledin the art without departing from the invention. It should be understoodthat various alternatives to the embodiments of the invention describedherein may be employed in practicing the invention. It is intended thatthe following claims define the scope of the invention and that methodsand structures within the scope of these claims and their equivalents becovered thereby.

1. A suture retainer comprising a retainer body and a plurality ofsuture attachment mechanisms spaced circumferentially about the retainerbody, each of the suture attachment mechanisms being adapted to hold asuture strand at a discrete attachment point.
 2. The suture retainer ofclaim 1 wherein each suture attachment mechanism comprises at least apair of teeth.
 3. The suture retainer of claim 1 wherein each sutureattachment mechanism is adapted to releasably hold the suture strand. 4.The suture retainer of claim 1 further comprising a suture guidemechanism adapted to maintain an angle between the suture strand and oneof the suture attachment mechanisms.
 5. The suture retainer of claim 4wherein the suture guide mechanism comprises a projection from theretainer body.
 6. The suture retainer of claim 4 wherein the sutureguide mechanism is adapted to be a first contact point of the suturestrand with the suture retainer.
 7. The suture retainer of claim 1wherein the suture attachment mechanisms comprise needle-end sutureattachment mechanisms, the suture retainer further comprising anon-needle-end suture attachment mechanism adapted to hold anon-needle-end of the suture strand.
 8. The suture retainer of claim 7wherein the non-needle-end suture attachment mechanism is disposedradially inward from each of the needle-end suture attachmentmechanisms.
 9. The suture retainer of claim 7 wherein the retainer bodycomprises a first member and a second member, at least a portion of thesecond member being adapted to be inserted into the first member tocomprise the non-needle-end suture attachment mechanism.
 10. The sutureretainer of claim 9 wherein the second member comprises a slot whichinteracts with the first member to hold the non-needle-end of the suturestrand.
 11. The suture retainer of claim 1 wherein the retainer bodycomprises a first member and a second member, at least a portion of thesecond member being adapted to be inserted into the first member to holda non-needle-end of the suture strand.
 12. The suture retainer of claim11 further comprising an alignment mechanism adapted to orient thesecond member with respect to the first member.
 13. The suture retainerof claim 11 further comprising a movable connection between the firstmember and the second member.
 14. The suture retainer of claim 11further comprising a snap connection between the first member and thesecond member.
 15. The suture retainer of claim 11 further comprising asuture guide mechanism projecting from the first member.
 16. The sutureretainer of claim 11 further comprising a suture guide mechanismprojecting from the second member.
 17. A method of securing a suture ina suture retainer comprising: providing a suture retainer comprising aretainer body and a plurality of suture attachment mechanisms spacedcircumferentially about the retainer body; and attaching a suture strandto the retainer body at each of the suture attachment mechanisms. 18.The method of claim 17 wherein the suture attachment mechanisms eachcomprise at least a pair of teeth, the method further comprisinginserting the suture strand between each of the pairs of teeth.
 19. Themethod of claim 17 further comprising releasing the suture strand fromthe suture attachment mechanisms after the attaching step.
 20. Themethod of claim 19 further comprising reattaching the suture strand tothe suture attachment mechanisms after the releasing step.
 21. Themethod of claim 17 further comprising contacting the suture strand witha suture guide to maintain an angle between the suture strand and one ofthe suture attachment mechanisms.
 22. The method of claim 21 wherein thecontacting step comprises contacting with the suture guide a portion ofthe suture strand between a point where the suture strand leaves atissue surface and a point where the suture strand contacts a sutureattachment mechanism.
 23. The method of claim 17 wherein the attachingstep comprises attaching a needle-end of the suture strand to needle-endsuture attachment mechanisms, the method further comprising attaching anon-needle-end of the suture strand to the suture retainer.
 24. Themethod of claim 23 wherein the retainer body comprises a first memberand a second member, the step of attaching the non-needle-end of thesuture strand comprising inserting at least a portion of the secondmember into the first member to hold the non-needle-end of the suturestrand.
 25. The method of claim 24 wherein the retainer body comprises amovable connection between the first member and the second member, theinserting step comprising moving the second member about the movableconnection with respect to the first member.
 26. The method of claim 24further comprising snapping the first and second members together.
 27. Asuturing method comprising: attaching a first end of a suture strand toa suture retainer; contacting a tissue contact portion of the suturestrand with tissue to be sutured, the tissue contact portion beingdisposed between the first end of the suture strand and a second end ofthe suture strand; and attaching the second end of the suture strand tothe suture retainer at a plurality of suture attachment points spacedcircumferentially about the suture retainer.
 28. The method of claim 27wherein the step of attaching the second end of the suture strandcomprises placing the second end of the suture strand between aplurality of pairs of teeth, each pair of teeth being disposed at one ofthe suture attachment points.
 29. The method of claim 27 furthercomprising detaching the second end of the suture strand from the sutureattachment points.
 30. The method of claim 29 further comprisingreattaching the second end of the suture strand to the suture retainerat the plurality of attachment points after the detaching step.
 31. Themethod of claim 27 wherein the step of attaching the first end of thesuture strand comprises inserting at least a portion of a first sutureretainer body member into a second suture retainer body member.
 32. Themethod of claim 31 wherein the step of attaching the first end of thesuture strand comprises placing the first end of the suture strand intoa slot formed in the first suture retainer body member.
 33. The methodof claim 31 wherein the inserting step comprises aligning the firstsuture retainer body member with the second suture retainer body member.34. The method of claim 33 wherein the aligning step comprises rotatingthe second body member to align a second suture retainer body memberalignment element with a first suture retainer body member alignmentelement.
 35. The method of claim 27 further comprising contacting thesecond end of the suture strand with a suture guide to maintain an anglebetween the suture strand and one of suture attachment mechanisms. 36.The method of claim 35 wherein the step of contacting the second end ofthe suture strand with the suture guide comprises making a first contactof the second end of the suture strand with the suture retainer.